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CMS Releases Proposed OPPS, Physician Fee Rules

Cheryl Clark, for HealthLeaders Media, July 9, 2013

Outpatient rule
Seven categories of items and services would be "packaged" or included in payment for a primary service:

1. Drugs, biological, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure;

2. Drugs and biologicals that function as supplies or devices when used in a surgical procedure;

3. Certain clinical diagnostic laboratory tests

4. Procedures described by add-on codes;

5. Ancillary services, such as a chest x-ray, that are assigned status indicator "X";

6. Diagnostic tests on the bypass list, and

7. device removal procedures.

CMS also is proposing to create 29 comprehensive ambulatory payment classifications, or APCs, to replace 29 existing device-dependent APCs, such as those that involve imaging services.

To further the agency's goals of using larger payment bundles to incent hospitals to provide care more efficiently, discourage upcoding, and set accurate payments, CMS wants to streamline five levels of outpatient visit codes into one single "Healthcare Common Procedure Coding System" or HCPCS code.

There would be one such HCPCS code "for each unique type of outpatient hospital visit (24 hour and non-24 hour).

"By collapsing the current five levels of codes to one level, CMS believes this proposal will remove incentives hospitals may have to provide medically unnecessary services or expend additional, unnecessary resources to achieve a higher level of visit payments under the OPPS, will reduce administrative burden and be easily adopted by hospitals, and will allow a large universe of claims to be utilized for rate setting."

For ambulatory surgical centers, the proposed payment update would be .9% for 2014.

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